An evidence-based approach to emergency ultrasound.

Paramedics bring into the ED an elderly man who is complaining of right-sided chest and abdominal pain. Earlier this morning, a friend had arrived at the patient's home and found him on the floor at the bottom of the stairs. The patient is in pain, somewhat altered, and unable to provide further details about what happened. After numerous attempts, the paramedics were only able to place a 22-gauge peripheral line. On examination, his blood pressure is 98/55 mm Hg, heart rate is 118 beats per minute, respiratory rate is 32 breaths per minute, oxygen saturation is 94% on a nonrebreather, and temperature is 36.0 degrees C (96.8 degrees F). His Glasgow Coma Scale score is 12 (eyes 3, verbal 4, motor 5). Given the unclear events surrounding his presentation and the concern for trauma, the patient is boarded and collared. His chest is stable but tender, and because of noise in the resuscitation room, you have difficulty auscultating breath sounds. The abdominal examination is notable for marked tenderness over the right upper quadrant and right flank, with some guarding. There is also mild asymmetric swelling of his right lower extremity. The patient is critically ill, his history is limited, and at this point the differential is quite broad. You consider the possibility of a syncopal episode followed by a fall, with a closed head injury, blunt thoracic trauma, and blunt abdominal trauma. His hypotension could be secondary to hypovolemia (dehydration or blood loss due to a ruptured aortic aneurysm), heart failure (left- or right-sided dysfunction), cardiac tamponade, tension pneumothorax, or sepsis. Your ED recently purchased an ultrasound machine, you wonder whether bedside ultrasound can help narrow the differential and guide your resuscitation. You call over one of your new faculty members who just finished resident training; a fortunate decision for both you and the patient.

Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis.

BACKGROUND & AIMS: Aggressive fluid resuscitation is recommended for initial management of acute pancreatitis. We performed a randomized controlled trial to evaluate the impact of a goal-directed fluid resuscitation protocol on systemic inflammation in patients with acute pancreatitis. We then determined the impact of resuscitation with lactated Ringer's solution, compared with normal saline. METHODS: We performed a randomized controlled trial of 40 patients with acute pancreatitis at 3 New England hospitals from May 2009-February 2010. Patients received goal-directed fluid resuscitation with lactated Ringer's solution, goal-directed fluid resuscitation with normal saline, standard fluid resuscitation with lactated Ringer's solution, or standard fluid resuscitation with normal saline. Systemic inflammation was measured on the basis of levels of systemic inflammatory response syndrome (SIRS) and C-reactive protein (CRP) level after 24 hours. RESULTS: The volumes of fluid administered during a 24-hour period were similar among patients given goal-directed or standard fluid resuscitation (mean, 4300 vs 4600 mL, respectively; P = .87). Goal-directed resuscitation did not significantly reduce incidence of SIRS, compared with standard resuscitation (11.8% vs 13.0%, respectively; P = .85) or levels of CRP after 24 hours (87.1 vs 69.2 mg/dL, respectively; P = .75). By contrast, there was a significant reduction in SIRS after 24 hours among subjects resuscitated with lactated Ringer's solution, compared with normal saline (84% reduction vs 0%, respectively; P = .035); administration of lactated Ringer's solution also reduced levels of CRP, compared with normal saline (51.5 vs 104 mg/dL, respectively; P = .02). CONCLUSIONS: Patients with acute pancreatitis who were resuscitated with lactated Ringer's solution had reduced systemic inflammation compared with those who received saline.

Development and validation of a web-based assessment tool for the extended focused assessment with sonography in trauma examination.

OBJECTIVES: Extended focused assessment with sonography in trauma (EFAST) examinations are routinely performed by emergency physicians and general surgeons as an integral part of trauma care. Although guidelines for competency in the EFAST examination exist, tools to assess competency are lacking. Our goal was to develop and validate a Web-based competency assessment tool to evaluate providers who perform the EFAST examination. METHODS: A multiple-choice test regarding the performance and interpretation of the EFAST examination was developed following National Board of Medical Examiner guidelines. Five emergency physician experts with fellowship training in emergency ultrasound established face and content validity. The test was administered to emergency medicine residents and ultrasound fellows. Concurrent validity was evaluated by assessing the correlation of scores on our test with guidelines set by the American College of Emergency Physicians (ACEP) for emergency ultrasound. Scores were analyzed, and statistical analysis was performed. RESULTS: Sixty-three emergency medicine residents and 2 ultrasound fellows from 2 residency programs completed the assessment tool. Examinees who met ACEP guidelines scored significantly higher than those who had not: 70.4% (95% confidence interval, 67.3%-73.4%) versus 48.3% (43.2%-53.5%). Evaluation of scores showed a significant correlation between an increased level of training, participation in an ultrasound rotation, and the number of EFAST and total ultrasound examinations performed with higher test scores. However, overall test scores were lower than initially anticipated. CONCLUSIONS: Use of this assessment tool for interpretation of EFAST images showed face and content validity. Score trends showed a significant correlation with existing ACEP guidelines, ultrasound experience, and the training level. Scores continued to improve with experience beyond ACEP recommended guidelines.

Screening for abdominal aortic aneurysm in asymptomatic at-risk patients using emergency ultrasound.

OBJECTIVE: Abdominal aortic aneurysm (AAA) is a deadly but often clinically silent disease. Patients at increased risk are elderly men with risk factors for vascular disease who may not have adequate screening through primary care. We sought to examine the prevalence and feasibility of screening for AAA in at-risk patients presenting for unrelated complaints using emergency physician-performed bedside ultrasound. METHODS: At-risk patients presenting with unrelated complaints were screened for AAA by emergency physician-performed ultrasound. Scan was rated as complete, limited, or inadequate, and time to complete scan noted. Patients with identified AAA were provided with appropriate follow-up and were followed to look at confirmatory imaging and clinical course. RESULTS: A total of 179 patients were screened, with 12 AAAs discovered (6.7%; 95% confidence interval, 3.9%-11.4%). Average time to perform the screening ultrasound was 141 +/- 135 seconds. Average discrepancy between emergency ultrasound and formal imaging was 3.9 mm. Of 12 (92%) patients, 11 were followed up, with repair recommended in 3 patients. CONCLUSION: The emergency department represents a potential opportunity for screening at-risk patients for AAA. Emergency ultrasound is a fast and accurate method for identifying patients with AAA who may benefit from follow-up or intervention.

Rate of decline in oxygen saturation at various pulse oximetry values with prehospital rapid sequence intubation.

BACKGROUND: A high incidence of desaturations has been observed during prehospital rapid sequence intubation (RSI). The rate of decline in oxygen saturation (SpO2) at various pulse oximetry values has not been defined with emergency RSI. Objective. To define the rate of SpO2 decline at various pulse oximetry values and identify a threshold below which active BVM should be performed during prehospital RSI. METHODS: Traumatic brain injury (TBI) patients undergoing RSI by prehospital providers were included in this analysis. The time period from the highest to the lowest preintubation SpO2 value was selected for review. The mean rate of SpO2 decline was calculated for each SpO2 value and then used to define a theoretical SpO2 desaturation curve. The rate of desaturation to hypoxemia (SpO2